Preferred Provider Organization (PPO)
Patients enrolled in a PPO will have a list of preferred providers or dentists to choose from. Preferred providers have a contract with the dental benefit plan. They assist in covering services provided based on the contracted fee schedule. Most PPO plans pay 100% for preventative care treatment (x-rays, exams, prophylaxis cleanings), 80% for basic restorative care (dental fillings), and 50% for major restorative treatment (crown, bridges, implants, partial/complete dentures). Dental care from a dentist who is not in the network may result in higher out-of-pocket costs. You can consult your dental provider to find out if Dr. Meinbach is contracted with your plan.

Covered Benefits are treatments that maybe recommended by your dentist, and are listed on your insurance fee schedule and accepted under the terms of your group plan.

Downgrading Procedures or Least Expensive Alternative Treatment is a clause they exists in many plans today. This means your plan recognizes there are different ways to treat a specific existing condition, but is only willing to help you cover the treatment in the least expensive way possible. The least expensive option is not always the best option. An example of this would be if the doctor recommends an implant and your plan will only cover much less expensive denture option. Other restorative examples include covering metal fillings instead of tooth-like or composite fillings or covering metal crowns instead of porcelain crowns. These situations result in down-coding. Your plan changes the codes submitted to a less complex or lower cost procedure than was reported by the dental office of what you actually received. The difference will always be the patients responsibility.

Optional Treatments are either not listed on your insurance fee schedule or may be more involved to restore a tooth back to its original function.

Plan Frequency Limitations include the number of times your plan is willing to pay for a certain type of treatment. Some patients may need a treatment more often to maintain good oral health. An example of this would be the plan that covers two cleanings a year, however due to periodontal conditions, or the way your body builds plaque, it may be recommended that you have a cleaning up to four times a year. Treatment decisions should be based on what is best for your oral health, not just what your plan will cover. Your hygienist can help make this determination.

Pre-Existing Conditions are conditions you had prior to enrolling in the plan. For example, if your policy has a missing tooth clause and you had a tooth extracted prior to being enrolled in the plan, benefits will not be paid for the replacement of the tooth that is missing whether it be via implant crown or bridge. When these situations arise, it doesn’t mean you don’t need the treatment because your plan will not cover certain conditions, you still need treatment to keep your mouth in optimal health.

Discount Plans
Discount Plans simply consist of the panel of dentists that have agreed to a reduced rate, with the subscriber being solely responsible for the entire portion of the bill. There is no billing or annual maximums for this type of coverage because all services are paid for at the time of service by the patient enrolled.

M Smile Plan – exclusively offered by M Dental
This is an in-office discount plan for patients not attached to an insurance plan. Ask about the plan at your next visit.